Why It's So Hard to Get Mental Healthcare in Rural America

When I was diagnosed with schizophrenia, living in rural Maine became a nightmare.

I've lived in rural Maine my entire life, which has been both a blessing and a curse. Maine is miles of ramshackle houses, roads worsening each spring season, miles of woods, old mill towns, and abandoned buildings. The sprawl of nothingness has a certain charm. There are acres of quiet, spaces to breathe.

By the time I was diagnosed with schizophrenia, though, I had started to feel differently. As chronic psychosis became part of my life, living in rural Maine became a major disadvantage.

I experienced my first psychotic break in 2013. Since then, I've been hospitalized six times, toggling between bouts of mania and depression. But as my illness worsened, it became harder and harder to find doctors who had the training to treat serious mental illness. Only 9 percent of doctors and 16 percent of registered nurses choose to work in rural areas, making it difficult—if not impossible—to find adequate treatment.

"In rural areas, too often there are too few providers to allow for the 'luxury' of seeking out the services of a specialist—they simply don't exist," Paul Mackie, president of the National Association for Rural Mental Health, told me.

"Depending on how 'rural' one is geographically, access to care and services range from acceptable to nearly impossible," he said. "The last I understood, approximately 90 percent of all psychologists and psychiatrists and 80 percent of clinical social workers are located in urban locations."

In the entire state of Maine, there are fewer than ten in-patient psychiatric hospitals where one could go during a mental-health crisis. Even getting to a psychiatric hospital, or a doctor, can be difficult. By definition, people in rural areas are isolated geographically, so the closest emergency room or specialist might be several hours away.

"I was in contact with a woman from western Nebraska who had to travel more than 90 miles, one way, every week, to take her child with behavioral issues to a child psychologist," John Crabtree, media director for the Center for Rural Affairs, told me. "That's fine if you have a car, and a license, and the ability to take time off from work. [But] when any of those things becomes problematic, your access to services are lost."

And it's not just isolation. People in rural areas are more likely to lack adequate health insurance or the means to pay for mental healthcare out of pocket. In Nebraska, for example, there are an estimated 201,000 people without health insurance, roughly half of whom "earn too much to qualify for Medicaid but too little to qualify for tax credits to buy coverage through the marketplace," according to a report by the Center for Rural Affairs. Without health insurance, my medications would cost more than $2,000 a month—an impossible sum for most people, but especially for anyone too sick to work.

Conditions in rural areas can also exacerbate mental-health problems. One in five adults suffers from mental illness, but in rural areas, rates of depression and suicide attempts are significantly higher than in urban areas, according to a report by the Center for Rural Affairs. Mostly because of isolation and poverty. For people who can't afford or access mental healthcare, some turn to self-medication, treating symptoms with drugs, alcohol, and self-harm, worsening their own illnesses. Where I live, it's easier to buy Klonopin from a dealer than it is from a psychiatrist.

After years of inadequate treatment, I swallowed an entire bottle of Gabapentin, a type of seizure medication. My goal was to die. When I was later strapped into an ambulance, the drive to the hospital was over an hour. I got better there, but after six days, I was discharged. It was far too soon, but there simply weren't enough beds to stay.

Mackie said his organization and others are investing in programs that will bring more attention to mental healthcare in rural areas, including programs that "[educate] people in rural areas to be able to provide assistance and care at a basic level," so as to start a pipeline of people who can later become licensed mental-health professionals.

"We know that people from rural areas are more likely to want to live and work in rural areas," he explained, so "the National Association for Rural Mental Health and others support focusing behavioral health education on communities and people who are statistically more likely to become rural providers."

The US Department of Health and Human Services's Office of Rural Health Policy has also outlined a list of potential solutions, including incorporating more telehealth technologies to connect people in remote areas to providers. But Mackie pointed out that many people in rural areas lack high-speed internet and "the current access to adequate bandwidth is too low for this to actually be viable."

For now, for many people in rural areas, it feels like there are no good solutions. Every time I've been hospitalized, it feels like a Band-Aid on a wound that needs stitches. And when I think back on my own suicide attempt, I think about how my story is all too common for those trapped in rural America, who are also suffering alone.